Knee Pain Questions to ask: Date of Injury Mechanism of Injury Able to walk or continue activity immediately after injury Able to walk or bear weight since injury Effusion/Bruising Mechanical symptoms 1st Injury? To evaluate on PE: Inspection/Palpation: obvious deformity, joint line tenderness,effusion ROM Ligaments:Lachman Menisci:McMurray Patellofemoral assessment:VMO,Patellar grind Gait Ligaments: ACL: Lachman’s 30 degree flexion PCL: Posterior sag sign, Posterior drawer test MCL:Valgus stress 30 degree flexion LCL:Varus stress 30 degree flexion Menisci: Joint line tenderness: tender medially:medical meniscus, tender laterally: lateral meniscus McMurrays: pain/pop on extension means + Lateral meniscus- IR tibia + valgus Medical meniscus-ER tibia + varus Patellofemoral: Effusion Crepitus VMO tone Patellar grind “Theater sign”-pain with standing up “circle sign”: pts point to knee and draw a circle around patella when asked where pain is Xrays to order: Bilateral AP weight bearing Lateral Merchants View
Questions to ask:
Date of Injury
Mechanism of Injury
Able to walk or continue activity immediately after injury
Able to walk or bear weight since injury
Effusion/Bruising
Mechanical symptoms
1st Injury?
To evaluate on PE:
Inspection/Palpation: obvious deformity, joint line tenderness,effusion
ROM
Ligaments:Lachman
Menisci:McMurray
Patellofemoral assessment:VMO,Patellar grind
Gait
Ligaments:
ACL: Lachman’s 30 degree flexion
PCL: Posterior sag sign, Posterior drawer test
MCL:Valgus stress 30 degree flexion
LCL:Varus stress 30 degree flexion
Menisci:
Joint line tenderness:
tender medially:medical meniscus, tender laterally: lateral meniscus
McMurrays: pain/pop on extension means +
Lateral meniscus- IR tibia + valgus
Medical meniscus-ER tibia + varus
Patellofemoral:
Effusion
Crepitus
VMO tone
Patellar grind
“Theater sign”-pain with standing up
“circle sign”: pts point to knee and draw a circle around patella when asked where pain is
Xrays to order:
Bilateral AP weight bearing
Lateral
Merchants View
Knee Exam:
Always compare sides when examining!!
Lachmans: http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-826792-1025.jpg
sensitivity 84% and specificity 93%
+:the tibia will feel unrestrained in forward movement
Suggests: ACL tear
Posterior Drawer Test: http://ajs.sagepub.com/content/26/3/471/F3.large.jpg
Clinician pushes in on tibia
+: if no discrete endpoint
suggests: PCL tear
Posterior Sag Sign: http://img.medscape.com/pi/emed/ckb/sports_medicine/84611-90514-281.jpg
+:difference in contour
suggests: PCL tear
McMurray Test: http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-826792-1028.jpg
sensitivity 53-59% and specificity 59-97%
+: pain/pop as you extend the externally rotated leg while applying varus stress
suggests: Medial Meniscus teat
+: pain/pop as you extend the internally rotated leg while applying valgus stress
suggests: Lateral Meniscus tear
Varus and Valgus Stress: : http://www.aafp.org/afp/2003/0901/afp20030901p907-f4.gif
+Valgus: if joint laxity/reproducible pain present
suggests: MCL(look for joint line tenderness)
+Varus: if joint laxity/reproducible pain present
suggests: LCL(look for joint line tenderness)
Patellar Grind Test: http://meded.ucsd.edu/clinicalmed/knee_chondromalacia.jpg
Hold the patella in place with your hand and ask the patient to contract their quadriceps muscle
+: if you reproduce pain
suggests: patellofemoral pain syndrome
VMO tone: http://www.t-nation.com/img/photos/2008/08-067-training/image027.jpg
+: if poor tone
suggests: patellofemoral pain syndrome
Effusion: http://meded.ucsd.edu/clinicalmed/extremities_right_knee_effusion.jpg
Ballotable Patella, milking of knee inferior to superior
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